临床案例Clinicalcase病理性近视致低视力康复Rehabilitationoflowvis.pptx

临床案例Clinicalcase病理性近视致低视力康复Rehabilitationoflowvisionduetopathologicalmyopia

目录Contents病历摘要Abstractofmedicalrecord第一部分Part1病例分析Caseanalysis第二部分Part2疾病介绍Introductiontodisease第三部分Part3教学病例讨论Teachingcases

教学病例讨论Teachingcases病例摘要第一部分Part1Abstractofmedicalrecord

一、患者基本信息Basicinformationofpatient患者，男性，51岁。Patient,male,51yearsold.主诉：自幼双眼视物模糊，加重近5年。Blurredvisioninbotheyessincechildhood,aggravatedfornearly5years.既往史：患者既往体健，否认高血压、糖尿病等病史，否认药物过敏史，否认眼部及其他全身手术病史。Previoushistory:Thepatientwasingoodhealthanddeniedmedicalhistoryofhypertension,diabetes,drugallergy,andeyeandothersystemicoperations.现病史：患者自幼视物模糊，诊断为“双眼近视”,一直坚持配戴眼镜，近5年来自觉双眼戴镜视力明显下降。发病以来，神志清，精神可，生命体征平稳，二便正常。Historyofpresentdisease:Thepatienthadblurredvisionsincechildhoodandwasdiagnosedasbinocularmyopia.Healwaysinsistedonwearingglassesandfeltthathisbinocularvisionhaddecreasedsignificantlyinthepast5years.Sincetheonset,themindisclear,thespiritcan,thevitalsignsarestable,andthebowelisnormal.体格检查：体健，全身及一般状态未见明显异常。Physicalexamination:healthy,noobviousabnormalityingeneralbodyandgeneralstate.

一、患者基本信息Basicinformationofpatient眼科检查Eyeexamination检查项目主要内容OD(D)OS(D)OU(D)检查项目Checkitem主要内容MaincontentsOD(D)OS(D)OU(D)原远用处方远距-12.00D=4.0(0.1)-12.00D=4.0(0.1)4.0(0.1)Originalfarsightednessprescription近距-12.00D=4.0(0.1)-12.00D=4.0(0.1)4.0(0.1)主觉验光远距-19.00/-1.00×90=4.3(0.2)-14.00/2.50×90=4.3(0.2)4.3(0.2)Subjectiverefraction近距-17.00/-1.00×90=4.3(0.2)-12.00/2.50×90=4.3(0.2)4.4(0.25)眼压Intraocularpressure16.3mmHg15.2mmHg对比敏感度视力0.640.64Contrastsensitivityvision对比视野Contrastfieldofview视野缩窄Narrowingofvisualfield视野缩窄Narrowingofvisualfield角膜映光法检查keratoscopy正位Rightposition遮盖试验Coveringtestexo,-8△@ND眼球运动EyemovementSAFE裂隙灯检查Slit-lampexamination双眼睑形态正常，启闭可，结膜清，角膜透明，前房深清，虹膜纹理清，